Provider Demographics
NPI:1245352095
Name:PULLIAM OPTICAL
Entity type:Organization
Organization Name:PULLIAM OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:770-787-7000
Mailing Address - Street 1:4167 HOSPITAL DR NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2565
Mailing Address - Country:US
Mailing Address - Phone:770-787-7000
Mailing Address - Fax:770-385-0813
Practice Address - Street 1:4167 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-0469
Practice Address - Country:US
Practice Address - Phone:770-787-7000
Practice Address - Fax:770-385-0813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0641190001Medicare ID - Type UnspecifiedMEDICARE